Henry Vigarelie, a private in the German legion, was wounded on the 18th of June, at the battle of Waterloo, by a musket-ball, which entered the right leg immediately behind and below the inner head of the tibia, inclining downward, and under or before a part of the soleus and gastrocnemius muscles, and coming out through them, four inches and three-quarters below the head of the fibula, nearly in the middle, but toward the side of the calf of the leg. In this course it was evident that the ball must have passed close to the posterior tibial and peroneal arteries; but, as little inflammation followed, and no immediate hemorrhage, it was considered to be one of the slighter cases. On the latter days of June he occasionally lost a little blood from the wound, and on the 1st of July a considerable hemorrhage took place, which was suppressed by the tourniquet, and did not immediately recur on its removal. It bled, however, at intervals, during the night; and on the morning of the 2d it became necessary to reapply the tourniquet, and to adopt some means for his permanent relief.
The man had lost a large quantity of blood from the whole of the bleedings; his pulse was 110, the skin hot, tongue furred, with great anxiety of countenance: the limb was swollen from the application of the tourniquet from time to time, a quantity of coagulated blood had forced itself under the soleus in the course of the muscles, increasing the size of the leg, and florid blood issued from both openings on taking the compression off the femoral artery. On passing the finger into the outer opening, and pressing it against the fibula, a sort of aneurismal tumor could be felt under it, and the hemorrhage ceased, indicating that the peroneal artery was in all probability the vessel wounded.
In this case there was, in addition to the wound of the artery, a quantity of blood between the muscles, which in gunshot wounds, accompanied by inflammation, is always a dangerous occurrence, as it terminates in profuse suppuration of the containing parts, and frequently in gangrene. Its evacuation therefore became an important consideration, even if the hemorrhage had ceased spontaneously.
The leg having been condemned for amputation above the knee, the officers in charge were pleased to place the man at my disposal: and being laid on his face, with the calf of the leg uppermost, I made an incision about seven inches in length in the axis of the limb, taking the shot-hole nearly as a central point, and carried it by successive strokes through the gastrocnemius and soleus muscles down to the deep fascia, when I endeavored to discover the bleeding artery; but this was more difficult than might be supposed, after such an opening had been made. The parts were not easily separated, from the inflammation that had taken place; and those in the immediate track of the ball were in the different stages from sphacelus to a state of health, as the ball in its course had produced its effect upon them, or their powers of life were equal or unequal to the injury sustained.
The sloughing matter mixed with coagulated blood readily yielded to the back of the knife, but was not easily dissected out. The spot which the arterial blood came from was distinguished through it, but the artery could not be perceived, the swelling and the depth of the wound rendering any operation on it difficult. To obviate this inconvenience, I made a transverse incision outward, from the shot-hole to the edge of the fibula, which enabled me to turn back two little flaps, and gave greater facility in the use of the instruments employed. I could now pass a tenaculum under the spot whence the blood came, which I raised a little with it, but could not distinctly see the wounded artery in the altered state of parts, so as to secure it separately. I therefore passed a small needle, bearing two threads, a sufficient distance above the tenaculum to induce me to believe it was in sound parts, but including very little in the ligature, when the hemorrhage ceased; another was passed in the same manner below, and the tenaculum withdrawn. The coagula under the muscles were removed, the cavity washed out by a stream of warm water injected through the external opening, the wound gently drawn together by two or three straps of adhesive plaster, and the limb enveloped in cloths constantly wetted with cold water. The patient was placed on milk diet.
On the 4th, two days after the operation, the wound was dressed, and looked very well; the weather being very hot, two straps of plaster only were applied to prevent the parts separating. On the 5th a poultice was laid over the dressings, in lieu of the cold water, the stiffness becoming disagreeable. On the 6th, as the wound, although open in all its extent, did not appear likely to separate more, the plasters were omitted, and a poultice alone applied. On the 8th and 9th it suppurated kindly; and on the 10th, or eight days from the operation, the ligatures came away, the limb being free from tension, and the patient in an amended state of health, his medical treatment having been steadily attended to.
The man was brought to England, to the York Hospital at Chelsea, and walked about without appearing lame, although he could not do so for any great distance. He suffered no pain, except an occasional cramp in the ball of the foot, and some contraction of the toes, which took place generally when he rose in a morning, and continued for a minute or two, until he put them straight with his hand; this I did not attribute to the operation, but to some additional injury done to the nerves by the ball in its course through the leg.
This case, which has been followed by many others equally successful, even after the femoral artery had been ineffectually tied, established the practice now followed in England by all educated surgeons; and is another of those great additions to surgery for which science is indebted to the Peninsular war.
198. It may be permitted to repeat, that if an artery such as the axillary be laid bare previously to an operation for amputation at the shoulder, and the surgeon take it between his finger and thumb, he will find that the slightest possible pressure will be sufficient to stop the current of blood through it. Retaining the same degree of pressure on the vessel, he may cut it across below his finger and thumb, and not one drop of blood will flow. If the artery be fairly divided by the last incision which separates the arm from the body, without any pressure being made upon it, it will propel its blood with a force which is more apparent than real. All that is required to suppress this usually alarming gush of blood is to place the end of the forefinger directly against the orifice of the artery, and with the least possible degree of pressure consistent with keeping it steadily in one position the hemorrhage will be suppressed. It is more important to know that if the orifice of the artery, from a natural curve in the vessel, or from other accidental causes, happen at the same time to retract and to turn a little to one side, so as to be in close contact with the side or end of a muscle, the very support of contact will sometimes be sufficiently auxiliary to prevent its bleeding.
In amputation at the hip-joint, the femoral and profunda arteries are frequently divided at or just below the origin of the latter, and bleed furiously if disregarded; but the slightest compression between the finger and thumb stops both at once. They never have given me the smallest concern in these operations, or others of a similar nature; and surgeons should learn to hold all arteries that can be taken between the finger and thumb in great contempt. It is quite impossible for a man to be a good surgeon—to do his patient justice in great and difficult operations attended by hemorrhage, unless he has this feeling—unless his mind is fully satisfied of the truth of these observations. While his attention ought to be directed to other important circumstances, it is perhaps absorbed by the dread of bleeding, by the idle fear that he will not be able to compress the artery and restrain the bleeding from it—that he may have half a dozen vessels bleeding at once—that his patient will die on the table before him. Once fairly in dismay, and the patient is really in danger; but, endowed with that confidence which is only to be acquired through precept supported by experience, he surveys the scene with perfect calmness: taking the great artery between the finger and thumb of one hand, he places the points of all the other fingers, of both hands if necessary, on the next largest vessels; or he presses the flaps or sides of the wound together until his other hand can be set at liberty by an assistant, or in consequence of a ligature having been passed around the principal artery. This is a scene sufficient to try the presence of mind of any man; but he is not a good surgeon who is not equal to it—who does not delight in the recollection of it when his patient is in safety, and his recovery assured. It was in consequence of what was then considered the too great boldness of the practice that my old friend, Sir Charles Bell, whose loss to science cannot be too much regretted, represented me seated on a pack saddle on the back of a bourro, (Anglice, a jack-ass,) on the top of the Pyrenees, expatiating on their merits (which he did not believe) to the descendants of the Bearnois of Henri Quatre on one side, and to the children of the lieges of Ferdinand and Isabella on the other; but no one now disputes their accuracy. The surgery of the Peninsular war was many years in advance of the surgery of civil life.